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COVID-19: what about outpatients?

The number of positive COVID-19 cases in Malaysia have more than quadrupled over the past week and is expected to continue increasing exponentially. There are 190 new cases reported yesterday (80% increase over 24 hours), bringing the grand total to 428. Only 42 cases (10%) have fully recovered and discharged from hospital, while 386 cases (90%) are still receiving treatment as inpatients. The higher rate of infection compared to the rate of recovery means that if no drastic action is taken now, the healthcare system would likely be burdened beyond its capacity soon.

Recognising the urgent need to lower the rate of the infection, the Malaysian Prime Minister recently requested that all public events, including international meetings, sports, social and religious events, are either postponed or cancelled until the end of April. In line with the announcement, Public Health Malaysia on its Facebook page also advised that any form of a mass gathering is avoided especially by those who already have symptoms of infection and that social-distancing of a minimum of 1 metre be practised to further mitigate the risk of infection.

The Director General of Health, Datuk Dr Noor Hisham Abdullah, has also listed several measures that will be taken by the Ministry of Health Malaysia to reduce the risk of COVID-19 infection in hospitals, namely:

  1. Visitors to hospitals will be limited to two (2) individuals per patient at any one time;
  2. Children under the age of 12 years are not allowed as visitors to the wards;
  3. Individuals with influenza-like symptoms (e.g. sore throat, cough, runny nose, fever, vomiting and diarrhoea) are not allowed as visitors to the wards; and
  4. Individuals with a high risk of infection, particularly those with chronic diseases or with low immunity (e.g. cancer patients on treatment) are not allowed as visitors to the wards, except under extenuating circumstances.

All these measures are put in place in our hope to flatten the curve of COVID-19 infection. We want the rate of infection to slow down (or perhaps cease completely) so that the healthcare system is able to deliver the required level of care to those currently infected.

But, the more I read the latest reports on the COVID-19 situation and recommendations that follow, the more I realise that there is a particular aspect about its risk mitigation that had been overlooked – outpatient visits. Although it seems so obvious, it had not been specifically addressed. Maybe we (in Ministry of Health) are too busy managing the risk of infection outside our organisation and those that come into our organisation through the inpatient channel, that we have failed to notice it. I hope I am wrong, but if I am right I hope what I am about to recommend is taken seriously and acted upon immediately.


Outpatient Clinics are mass gathering, no?

During my outpatient appointment two weeks ago, there were more than 250 patients waiting in a single clinic. If we consider the total number of clinics within the large outpatient clinic complex, the number of congregated patients would have easily reached thousands. By definition, it should be regarded as a mass gathering. But, healthcare administrators and healthcare professional argue that outpatient appointment attendance is considered necessary and therefore could not be avoided. Some even argue that the appointments were given pre-outbreak, so it is too late to cancel them.

Outpatients have co-morbidities

Not only are patients unintentionally gathering in massive numbers in the outpatient clinics (a location of particularly high risk), they (the ones who gather there) are the ones with the highest risk. They all have co-morbidities that puts them at risk of being infected. If they do become infected they have a poorer prognosis than the general population and are very likely to require intensive care. So, why are they still there? They are the ones that we (in MOH) are particularly worried about and yet our actions (or inactions) are still putting them at risk of being infected.

Social distancing is not possible in Outpatient Clinics

If you’ve ever waited in outpatient clinics you would know that the social distancing recommendation is simply not possible in this setting. Most government outpatient clinics have small waiting areas, and the chairs which are closely arranged are fully occupied most of the time. This makes the 1-metre social distance recommendation inapplicable in this situation. And not to mention that long waiting time in these clinics has the potential to further worsen this situation. Again, our recommendations have failed to take into consideration those who are at high risk and are sitting right in front of us.

The solution

Reduce the number of patients in the mass gathering occurring in many outpatient clinics throughout the country immediately. Not all outpatient appointments are created equal. Some are less urgent than others. But, we cannot rely on patients’ own initiatives to call the clinics and reschedule their appointments. Many of them wouldn’t even be able to tell if their appointment is considered as urgent or non-urgent. Therefore, it is imperative that outpatient clinic staffs and officers start screening outpatient appointments for the next several weeks and stratify them according to their urgency.

Those considered as non-urgent must be called to reschedule their appointments to many months ahead. Also, they must be informed of the reasons for the decision, to ensure complete understanding. This entire process must be repeated until the outbreak is over. By taking this action, we would be able to significantly reduce the risk of infection for the group of people with the highest risk and poorest prognosis (should they become infected). At the same time, those who still need to attend their outpatient appointments would be able to observe the 1-metre social distance as per recommendation.


The situation is only going to get worse before it gets any better. Although most recommendations from the Malaysian government and health authorities may be sufficient to keep the general public from being infected, they have not adequately addressed the high-risk population which is the outpatients. This group patients are particularly at risk when attending clinic appointments as it resembles mass-gathering which makes social-distancing impossible. We need to be proactive and do more than just telling them to reschedule their appointments. They must be our priorities now.

Resources:

  1. Kenyataan Akhbar YBMK 15 Mac 2020 – Situasi Semasa Jangkitan Penyakit Coronavirus 2019 (COVID-19) di Malaysia
  2. “Tangguhkan Mass Gathering” by Public Health Malaysia
  3. COVID-19: Semua perhimpunan, mesyuarat antarabangsa ditangguh sehingga 30 April – PM

Image by Tumisu from Pixabay

 

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